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Drug management – do we need to change our practice?

“If you always do what you’ve always done, you’ll always get what you’ve always got.” Mark Twain.

The above quote is an interesting and useful principle. I am writing this just after the General Election, and thinking that it will be interesting to see if our political leaders can adhere to this. Sadly, I am not holding my breath. At the same time, Trump and Kim Jong-un are dancing around each other in an increasingly menacing fashion. Thinking outside the square is difficult, not intuitive and not rewarded. Mark Twain’s words resonated with me as I have spent much time thinking about drug management, subsequent to the HDC case and reflecting on my own practice and how I should respond to this.  I have also been asked by others if there is evidence to support a change in how we manage drugs. Hence, I have done a little bit of searching. Bottom line, I think there is evidence and we should probably be changing what we do. Will this change be easy? No, of course not, however it is not likely to be any harder than other changes that we as individuals face in current times. For example, I had not heard the term “Range Anxiety” until recently. This refers to the battery capacity of electric cars; until recently enabling a travel distance of just over 100kms and then requiring significant charge time – if you could find a charging station. However, battery capacity is rapidly increasing, and it may even be possible to charge up while driving.

So, when it comes to drug error, what are the issues? I think these can be divided into three:

  1. Acknowledging that we do make errors, looking at how often these errors occur
  2. Does this cause a problem?
  3. Do the suggested solutions reduce errors?

The answer to one is ‘more frequently than we think’ and to two and three yes.

The evidence:

  1. No one disputes that error is a constant reality in any human endeavour. In terms of drug errors, the problem was first identified back in the late 70s. (1)
    The often-quoted frequency of drug error in anaesthesia (including in a previous blog I wrote) is that reported by Webster et al of 1:133. (2) A more recent study suggests a much higher frequency of 1:20, or every second surgical episode of which one third leads to harm. (3) If this is the case, it is a disaster that needs to be addressed. However, there is some disconnect in that this is certainly not the perception I get from my everyday practice. Indeed, when one drills down into the errors, many are not what we would (rightly or wrongly) classify as an error. For example, many are documentation errors – or mainly absences, such as recording a change in the rate of TCI propofol. To be fair, some of these are a problem. I have sometimes questioned myself as to whether I gave antibiotics or an antiemetic. (Okay, and I may not record all the doses of vasopressor given – will stop fessing up now.) However, the money really is in slips and syringe swaps. These are execution errors, as opposed to intention errors – so the plan is good, but the process comes a cropper.
  2. So, is this a problem? I think this is a most interesting question and to some extent depends on one’s perspective. As anaesthesiologists, my impression is that we have a higher tolerance for drug errors than most other groups. As in any occupational group, one’s tolerance for variance seems higher than for the non-experts. Take for example loggers. From time-to-time the things they do with chainsaws seem really brainless; but most of the time they get away with it, but when they don’t…well, we see the results. I wonder if the same can be said about our attitude to drug safety? I think this explains many of the HDC case reports. For example, a patient relays that they have an adverse reaction to morphine. Their expectation is that this drug will now not be administered. Our view is that they had a side effect and the drug is safe to administer – so a major disconnect that can lead to subsequent misunderstanding, complaints and problems. In addition, if one steps back, it’s arguably surprising that we do not make more errors. We prescribe, prepare, re-label and dispense drugs without concurrence from another healthcare provider, all while working in a complex, dynamic, and sometimes chaotic environment.
  3. Does the evidence show that technology can help us in the quest to reduce error? Well yes, it does. Let’s look at the type of mistakes analysed, and proposed solutions. A recent BJA publication has summarised this data and even ranked suggested solutions, many of which we have incorporated into our practice. (4) However, there are a few further techniques that we have been slow to adopt. The Anaesthesia Patient Safety Foundation promotes standardization, barcode medication administration, and the use of pre-filled or premixed syringes to reduce medication error. (5) These are also strongly supported in the above BJA article. Double-checking also ranks highly. This is a two-edged sword and cynics (I include myself) fear that if anything this may reduce vigilance in that both checkers unconsciously pass responsibility to the other. There is evidence for this but also that if the check is done in an active, rather than passive fashion it is useful. The anaesthetic assistant could easily provide this service as they are usually immediately available and there is a move to increase the utility of this group. The surrogate double checker is of course a barcode scanner such as Safersleep.

Rightly or wrongly, we need to be cognisant of the expectations of consumers and regulators and to build this into our practice. Bottom line, the bar only ever goes up and we have to adjust.  I think the expectation is that we will incorporate most, if not all, of the suggested recommendations in the BJA paper. If an error occurs and the recommendations have not been adhered to, I suspect this will be viewed as a violation. If an error occurs despite following the recommendations, then hopefully a ‘just culture’ approach will apply.

Once again, and perhaps now more than usual – may the force be with you.


  1. Webster CS, Merry AF, Larsson L, McGrath KA, Weller J: The frequency and nature of drug administration error during anaesthesia. Anaesth Intensive Care 2001; 29:494–500
  2. Nanji KC, Patel A, Shaikh S, Seger DL, Bates DW. Evaluation of perioperative medication errors and adverse drug events. Anesthesiology. 2016;124:25–34.
  3. Cooper JB Preventable Anesthesia Mishaps: A study of human factors. Anesthesiology 1978;49:399-40.
  4. Wahr JA, Abernathy JH 3rd, Lazarra EH, et al. Medication safety in the operating room: literature and expert-based recommendations. Br J Anaesth. 2017;118:32–43.
  5. Brown, LB: Medication Administration in the Operating Room: New Standards and Recommendations:AANA Journal. Dec 2014, Vol. 82 Issue 6, p465-469.